[Severe precocious pre-eclampsia : how to manage the feto-maternal conflict of interest]

BACKGROUND

The HELLP syndrome is usually treated by rapid termination of pregnancy as the most effective way of limiting the risk of disease aggravation and maternal complications. The drawback is the risk of fetal complications due to prematurity when pregnancy is terminated before 32 weeks gestation. A controlled study has suggested that corticosteroid therapy could be effective in early HELLP syndrome.

PATIENTS AND METHODS

From January 1, 1996 to March 1, 1999, we treated patients presenting early HELLP syndrome defined as platelet counts below 150,000 and ALAT above 50 U/l prior to 32 weeks gestation with dexamethazone (Soludecadron((R))) via intravenous administration of 10 every 12 hours to the end of pregnancy or until platelet counts rose above 150,000.

RESULTS

Among 14 patients with early HELLP syndrome, 10 were treated (including 5 primiparous women). Six patients among the 10 had platelet counts between 50,000 and 100,000. Mean term at the first injection of dexamethazone was 29 weeks 3 days. Platelet counts rose and transaminase levels fell in all patients. Pregnancy was prolonged 7 2 days. The only maternal complication was one case of disseminated intravascular coagulation. There were no neonatal deaths.

DISCUSSION

Our results are similar to those reported in the literature but such a treatment scheme can only be instituted within a rigorously controlled monitoring system in a unit with neonatal and maternal intensive care facilities. This protocol remains safe for patients with HELLP syndrome whose platelet count remains at least above 50,000.

[Multiple vulvar cystic and papillary fibroadenomas]

We report a new case of multiple vulvar fibroadenoma arising in a 47-year-old woman. This papillary and cystic lesion shares similarities with papilliferum hidradenoma and mammary fibroadenomas. After describing clinical and pathological characteristics, we try to detail its origin according to the literature and particularly its relationship with anogenital sweat glands and ectopic mammary glands.

[Comparison of blood loss during cesarean section and during vaginal delivery with episiotomy]

OBJECTIVE

The aim of our study was to compare blood loss during vaginal delivery with episiotomy and during cesarean section, to determine risk factors, and to determine whether clinical assessment of blood loss at delivery is well-evaluated.

PATIENTS AND METHODS

We retrospectively matched 97 vaginal deliveries with episiotomy with 97 cesarean deliveries which has occurred between 1 November 1991 and 30 April 1993. Matching criteria were age, parity, term and birth weight. Blood loss at delivery was defined by a drop in hematocrit greater than 10% between the pre-delivery anesthesia work-up and the laboratory results 3 days post-partum.

RESULTS

We found that hemoglobin and hematocrit fell more after vaginal deliveries than after cesarean section (p < 0.05 and p < 0.01). The fall in hemoglobin level and hematocrit were significantly greater after forceps delivery with episiotomy than after spontaneous vaginal delivery (p < 0.01 and p < 0.01). Among the vaginal deliveries, 11 showed laboratory criteria corresponding to blood loss at delivery despite clinical diagnosis in only 2 of them. Unwarranted clinical diagnosis of blood loss at delivery was however made 11 times after vaginal delivery and 19 times after cesarean (20%).

CONCLUSION

Our findings demonstrate that blood loss during vaginal delivery with episiotomy is greater than during cesarean section and affirms the determining role of forceps use in association with episiotomy in this blood loss. Clinical assessment of blood loss at delivery lacks precision.

[Maternal morbidity and mortality related to delivery]

Maternal mortality related to delivery is theoretically easy to quantify and constitutes a good indication of the security and quality of obstetrical care. Although its incidence continues to decrease in France, it is still higher than in several of our European neighbors. Hence management of pregnancy is still deficient in this country. Fifty per cent of deaths occur at the time of delivery or immediately thereafter, and case analysis shows that the majority of these deaths, particularly those due to haemorrhage, could have been avoided by earlier diagnosis or better adapted treatment.

External cephalic version after previous cesarean section: a series of 38 cases

OBJECTIVE

To determine if external cephalic version (ECV) is a reasonable alternative to repeat cesarean section in case of breech presentation.

STUDY DESIGN

Retrospective study of 38 women with one previous cesarean section and a breech presentation after 36 weeks of gestational age who have had at least one experience of ECV. Statistics used the Fisher's test with significance when P<0.05.

RESULTS

Version attempts were successful in 25 of the 38 women (65.8%). Seventy-six percent of the successful version women went on to have vaginal birth after cesarean section. A total of 19 successful vaginal deliveries occurred (50%). Success rate of ECV was lowered when breech was the indication of the previous cesarean section. The vaginal delivery rate was increased after successful ECV in patients previously vaginally delivered, but this difference did not reached significance (P=0.057). No maternal or neonatal complications occurred.

CONCLUSION

ECV is acceptable and effective in women with a prior low transverse uterine scar, when safety criteria are observed.

C-reactive protein levels at the onset of labour and at day 3 post-partum in normal pregnancy

OBJECTIVES

To record maternal serum C-reactive protein levels during normal onset of labour and normal puerperium and to evaluate if inflammation or infection could be predicted during these two periods when serum C-reactive protein is increased.

METHODS

Eighty-five pregnant women were enrolled in a longitudinal prospective study and had a blood sample to assess serum C-reactive protein levels on admission to the labour ward for normal onset of labour and at day three post-partum. Inclusion criteria were no previous history, a normal single pregnancy, normal vaginal delivery and an uneventful post-partum course. Twelve non-pregnant women of the same age constitued a control group. An automatic Behring Nephelometer was used to measure serum C-reactive protein concentrations. The Student's t-test (significance p < 0.05) was used for statistical analysis.

FINDINGS

C-reactive protein was significantly increased during the onset of labour (4.10 +/- 2.79 mg/L) and reached very high levels during the post-partum period (24.07 +/- 18.28 mg/L) compared to the standard normal serum C-reactive protein level in a population of non-pregnant women of the same age (2.39 +/- 0.07 mg/L).

INTERPRETATION

Increased serum C-reactive protein has been reported to be a marker for subclinical infection during pregnancy in various situations including premature labour and premature rupture of membranes and for complications occurring during puerperium such as thrombophlebitis, thromboembolism or endometritis. This interpretation depends on which upper limit is considered as abnormal. Because serum C-reactive protein was raised during the onset of labour, values of less than 10 mg/L could not be considered as a marker for infection during this period. Elevated serum concentrations of estrogen, progestogen and prostaglandins during labour might be one explanation for those physiological changes. Normal vaginal delivery could be compared to a surgical procedure and tissue injury consecutive to vaginal birth as reflected by a dramatic increase in C-reactive protein. More studies using nephelometry are needed to determine normal and upper values of C-reactive protein during pregnancy.

[How many abdominal hysterectomies can be avoided by laparoscopic surgery?]

Laparoscopic hysterectomy performed for benign uterine lesions without prolapse is becoming more and more popular. This surgical route has some of the advantages of the vaginal route and could avoid numerous abdominal hysterectomies. Our experience shows that most of abdominal or laparoscopic hysterectomies could be done using the vaginal route which is for us the reference. One question about laparoscopic hysterectomy is: can we perform this technique to avoid abdominal hysterectomy when the vaginal route looks impossible? To answer this question, we retrospectively studied 171 hysterectomies. The laparoscopic hysterectomy rate should not reasonably exceed 10 to 15%, yet is much higher for the promotors of this technique of which advantages compared with vaginal hysterectomy are not clearly demonstrated.

[Biological diagnosis of premature rupture of membranes: respective values of diamine oxidase activity compared to vaginal fluid pH (Amnicator)]

OBJECTIVES

To compare the sensitivity (Se), specificity (Spe), positive predictive (PPV) and negative predictive (PNV) values of 2 tests used routinely for suspected premature rupture of the membranes (PROM) and their implication in the management of such cases.

PATIENTS AND METHODS

From 1 November 1995 to 31 July 1996, 87 patients: 16 with obvious PROM on physical examination (group I) and 71 with suspected PROM (group II) were tested with both DAO and Amnicator. PROM was arbitrary confirmed in group II when delivery occurred within 48 hours after the diagnosis was suspected. The corrected chi 2 test was used to compare both tests results in group II.

RESULTS

In case of obvious PROM, the sensitivity of the DAO and Amnicator tests were 75 and 87.5% respectively. Eleven patients from group II delivered within 48 hours following admission and the 2 tests results were respectively: Se 90.9 and 81.81%, Spe 100 and 83.33%, PPV 100 and 52.63% and PNV 98.36 and 96.15%. DAO gave better results in terms of Spe and PPV (p < 0.05).

COMMENTS

The DAO test remains a reference test when PROM is suspected but when it is not available (during night or week-end), the quite good negative predictive value of Amnicator could avoid unnecessary hospitalisation and permit later DAO test.

[Prophylactic amnion infusion during labor. Apropos of 195 cases]

OBJECTIVE

To show that intrapartum prophylactic amnioinfusion in case of oligohydramnios or particulate meconium-stained amniotic fluid could be beneficial.

STUDY DESIGN

From March 1st, 1993 until December 31st, 1996, 6845 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (118 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2)(77 patients) were included. Each group was compared with a historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2)), age, parity, gestational age, and duration of labor. Statistical analysis was performed using the Student's t test and the Fisher's exact test when appropriate with a level of significance of p < 0.05.

RESULTS

The mean infused volume was 883 ml in G1 and 751 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (14% versus 25%, p < 0.05) and of assisted deliveries for fetal distress between G2 and CG2 (5% versus 18%, p < 0.02). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also find a difference between G2 and CG2 (5% versus 14%) which was not significant. No neonatal or maternal adverse effects happened in this short study.

COMMENT

Amnioinfusion is easy to perform during labor in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic amnioinfusion performed in case of oligohydramnios and abnormal fetal heart rate.

Indications of laparoscopic hysterectomy

OBJECTIVE

To determine when vaginal hysterectomy is contra-indicated and abdominal hysterectomy should be performed. To assess when laparoscopic surgery can avoid the abdominal procedure, and to determine the indications of this new technique in case of benign uterine lesions without prolapse.

MATERIALS AND METHODS

A retrospective study of 171 hysterectomies performed by the same surgeon for benign uterine lesions without prolapse. When possible the vaginal route was chosen and the following criteria were studied: indication for hysterectomy, previous surgery, uterine weight, duration of the procedure, intra- and post-operative bleeding, complications and recovery time. Statistical analysis was performed using the Chi2 test and the Fisher's exact test when appropriate with a level of significance of p < 0.05.

RESULTS

One hundred and nine vaginal (60.4%) and 62 abdominal (39.6%) hysterectomies were performed and the main indication was menometrorrhagia (respectively 97 (89%) and 49 (79%) cases). The indication for abdominal surgery was an enlarged uterus in 47 patients (76%). In 10 cases (6%) laparoscopy was indicated because of severe endometriosis, previous abdominal surgery or a suspect adnexal cyst. No complications occurred in either group. The duration of the procedure, blood loss and recovery time were lower in the vaginal group (p < 0.05).

COMMENTS

Uterine volume limits vaginal hysterectomy, and this cannot be overcome by laparoscopic surgery. Only severe adhesions and endometriosis are more amenable to laparoscopic hysterectomy. The laparoscopic hysterectomy rate should not reasonably exceed 10 to 15%, yet is as high as 63% in some studies. Further studies are needed to determine the value of laparoscopic hysterectomy relative to the vaginal route.

Prophylactic intrapartum amnioinfusion: a controlled retrospective study of 135 cases

OBJECTIVE

To show that intrapartum prophylactic amnioinfusion (AI) in case of oligohydramnios or particulate meconium-stained amniotic fluid could be beneficial.

STUDY DESIGN

From the first March 1993 until the 30th June 1995, 4031 women were delivered at the University Hospital of Poitiers. Patients presenting with oligohydramnios (G1) (71 patients with an amniotic fluid index below 5 cm) or a particulate meconium-stained amniotic fluid (G2) (64 patients) were included. Each group was compared to an historical control group constituted retrospectively according to the following criteria: oligohydramnios (CG1), particulate meconium-stained amniotic fluid (CG2), age, parity, gestational age and duration of labor. Statistical analysis was performed using the Student's t-test and the Fisher's exact test when appropriate with a level of significance of P less than 0.05.

RESULTS

The mean infused volume was 893 ml in G1 and 734 ml in G2. A significant difference was found in terms of cesarean section between G1 and CG1 (11.3 vs. 24.5%; P < 0.05) and of assisted deliveries for fetal distress between G2 and CG2 (12.5 vs. 23.43%; P < 0.05). No other significant difference was found between the study groups and their control for all other studied criteria. When considering more specifically the presence of meconium below the vocal cords we also could not find any significant difference between G2 and CG2 (1.6 vs. 9.4%; P = 0.05). No neonatal or maternal adverse effect happened in this short study.

COMMENT

AI is easy to perform during labour in case of oligohydramnios or particulate meconium-stained amniotic fluid. In case of oligohydramnios, a decreased rate of cesarean sections has been observed in the infused group. Considering patients with particulate meconium-stained amniotic fluid, less interventions for fetal distress and neonates with meconium below the vocal cords has been found in the infused group. Further prospective evaluation is needed to confirm these results in case of particulate meconium-stained amniotic fluid and to compare the advantage of prophylactic versus therapeutic AI performed in case of oligohydramnios and abnormal fetal heart rate.

[Cervical maturation by repeated applications of prostaglandin E2 gel. 186 cases]

OBJECTIVE

A prospective clinical trial of cervical ripening with intracervical prostaglandin E2 gel in repeated administrations was performed.

STUDY DESIGN

One hundred eighty-six patients were enrolled in this prospective trial between 01/01/89 and 31/12/93. these patients with unripe cervix (Bishop score < 5) required induction of labor because of pregnancy disorders. Mean patient age was 28.2 years (range 15 to 43), mean gestational age was 39.2 week's gestation (range 33 to 43) and mean parity was 1.8 (range 1 to 10). Our exclusion criterias were as follow: twin pregnancies, breech presentation and premature rupture of membranes. A 0.5 mg prostaglandin E2 gel was administered into the cervix every four hours maximal of three doses before induction of labor with oxytocin. Maternal and neonatal results were reviewed.

RESULTS

Patients required a single dose of gel in 19.9% of cases, two doses in 26.3% and three doses in 53.8%. Induced labor during cervical ripening occurred in 55.4% of patients. A cesarean section was necessary in 22% of cases. This rate was both significantly related to the initial Bishop score and to the Bishop score at the end of the procedure. Patient with induced labor during the cervical ripening had a significantly lower cesarean section rate compared to these who needed induction with oxytocin (10.7% versus 33.8%; p < 0.01). The uterine hyperstimulation rate was 1.6%. A 1 min Apgar score less than 7 occurred in 1.1% of neonates.

COMMENTS

Our results do not demonstrate benefit of repeated administration comparison to a single administration described in literature. Maternal and neonatal morbidity is low in this study but cervical ripening should be used only when pregnancy disorders require prompt delivery within twenty-four hours.

[Hepatic cytolysis caused by tocolytic treatment using micronized natural progesterone]

Micronized natural progesterone is often prescribed alone or in association with beta-agonists in the treatment of preterm labor in France. We observed drug-induced hepatitis in 4 such patients. The main manifestation of liver disease was pruritus. After drug withdrawal, elevated transaminase levels continued to rise for one week then normalized within 10 to 30 days. The imputability of this undesirable effect was assessed and considered to be likely. The effectiveness of micronized natural progesterone in the prevention of premature delivery and in decreasing perinatal mortality and morbidity has not yet been proven. This drug should therefore be used with care, keeping in mind the risk of hepatitis, particularly in patients presenting with pruritus.

[Maternal mortality in Guinea: magnitude and perspectives]

In recent years maternal mortality in developing countries has become a public health priority for international organizations. However, measuring the true magnitude of this problem is the subject of much methodological debate. In less than a century, the rate of maternal mortality in most industrialized countries has decreased one hundred-fold. In contrast, the rate remains very high in most developing countries, particularly in Africa. In this article based on the studies conducted in Guinea we review various operational proposals which may contribute to improving maternal health and reducing maternal morbidity and mortality, with particular reference to the work of the French speaking organization "Santé Maternelle Internationale".

[The role of ultrasound-guided puncture in the evaluation of liquid tumors of the ovary]

Twenty percent of liquid tumors of the ovary are persistent functional cysts. Laboratory tests of the cystic fluid should make it possible to distinguish between functional cysts and organic cysts. In 170 patients derived from a multicenter study and presenting with a liquid tumor of the ovary (including 9% of cancers), samples of the cystic fluid and serum were taken from the patient and the ACE, CA 125, CA 19-9 markers, estradiol and Progesterone were assayed. The results of these assays were subjected to computerized analysis and compared with the pathological findings. The assays were able to discriminate between organic cysts and functional cyst with 93% of sensitivity and 95% specificity. The insufficient reliability of this evaluation justified a second study (in progress) which is limited to the study of pure fluid tumors with thin walls, no partitions, no vegetations and measuring less than 8 cm in diameter in which the incidence of cancers is very low. This study should fine tune the initial findings and result in a sensitivity approaching 100 percent. If this hypothesis is confirmed, it should be possible to include ultrasound-guided puncture carried out under closely defined conditions in the therapeutic decision trees for liquid cysts of the ovary.